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Thursday, September 23, 2010

5.(11-14) Arthritis, My Neck, Fibromyalgia, Tendonitis, Thrombophletibits


Physician's Notebooks 5 - http://physiciansnotebook.blogspot.com - See Homepage
  Major update in process 03 Jan.2018
In order, Chapter 11, The Skeleton-Muscle System, 12, Dem Bones, 13, Arthritis and finally, Chapter 14 has personal experiences with bony joints.
Chapters on Supports & Connections
       11. The Skeleton-Muscle System
– is what gets us around or allows each of us to say I'm Still Standin' even when we are not moving. As an 85-year-old, for me the most important health issue, to paraphrase EditElton John, is Am I still standin'?  My low back is, practically, falling apart and walking is constantly painful and I need daily 325 mg aspirin and/or 500 mg acetaminophen. And it caught me flat-footed so to speak. I paid good attention to my heart, brain and other vital organs to achieve healthy longevity but I mostly ignored my bones, muscles and joints. And now because of my not watching my back and neck for 70 years: my poor posture, my frequent careless falls, I am near to being incapacitated and only barely still standin'
Today I give young readers the following advice: Start from childhood (with good posture and avoidance of bad posture study habits). Pay attention to avoiding falls and be sure your home environment has built-in soft landings like Japanese tatami floor or western style soft flooring. I kid you not: take me seriously; more seriously than I took my low back and lower extremities.
12. Dem Bones
 Here are preventives against fractures and other bone or joint damage: 1) Keep Body Mass Index (BMI) below 25 and get it down to 20 by after age 60. 2) Pay attention to adequate calcium and vitamin D intake. 3) Avoid accident and do not carry too heavy weights. 4) Practice good posture when walking, standing and lying down. When walking, look up and straight ahead; not down except brief glances to watch for tripping objects, and Walk strong! Don't Slouch or Shuffle! When standing, stand straight When lying down, lie mostly flat on back, and stretch and elevate extremities as part of regular lie down exercise; in bed do not scrunch up in fetal position on side.
13. Arthritis and Joint & Extremity Pain
The descending order table of topics as they appear in text. You may locate each by search & find or scrolling down.
Arthritis is 
Trauma
Abnormal Position Stretch-Joint Pain
Arthritis of the back
OsteoArthritis (a.k.a. Degenerative Arthritis) of Hands, Feet and Larger Joints like the Hip 
Preventives
Report of Hip Replacement
Immune System Arthritis  - Rheumatoid
Crystal Deposition Arthritis – Gout
Infection in Joint
Arthritis after Infectious Disease
Pain of Muscle, Tendon, Bone, Cartilage, Ligament & Blood Vessel
Bursitis and Bursal cysts - Bakers Cyst, Ganglion
Bone Pain
Thrombophlebitis - DVT - Pulmonary Embolism
Reynaud's Syndrome and Reyaud's Disease
Fibromyalgia
Whiplash Injury Magic Cure!
Lumbo-sacral (Lumbago) and Sacroiliac L-S Pain Disc Syndrome
Inter-vertebral disc hernia
End Note on low back pain - good effect of firm mattress
Corticosteroid injections
Malingerer and Neurotic
Arthritis is inflammation of joint; it can be from repeated minor trauma; it can be the wear or tear of aging, or an inherited or acquired tendency of an immune system to attack its own joint, or from chemical crystallization in joint, or from infection. Or it can be from bad posture and frequent falls. Acute arthritis causes swelling and redness in the joint, but in chronic arthritis the symptom and sign is deformation and disordered function and eventually debilitating soreness. Any joint may get affected but the hand, foot, knee, hip or back are affected most often. (In my case at age 85, my left hip osteoarthritis has reached a point where I almost can't walk on it because of the fluctuating pains; I connect this with my poor low-back care when I was younger and frequent falls)
Trauma 
Accident or repeated minor bump; any emergencies should be obvious; they involve disruption and bleeding and need inactivity to heal. But although they should be obvious they are often carelessly ignored as I ignored in my case. 
Abnormal Position Stretch-Joint Pain:  Particularly in the knees, holding an extremity in abnormal stretch position too long can result in several days joint pain on movements. In the knee it comes mainly from sitting in train coaches with your feet up and heels on opposite facing seats causing excessive tension on extensor tendons of the knee (straightened knee syndrome).
Arthritis of the back is from lifetime calcium loss and older age low sex hormone levels, trauma of falls and also from poor posture. In upper part it leads to the bent cervical-thoracic spine that at worst is dowager hump. Stand up straight. In lower part it is caused by vertebrae collapse disc problems and low back pains.
OsteoArthritis (a.k.a. Degenerative Arthritis) of Hands, Feet and Larger Joints like the Hip is old age related and is caused by lifetime small traumas as the examples, of the old-age typist's arthritis and ballet dancer arthritis. My left hip arthritis was due to accidental falls on left buttock during younger life.
Preventives vary with location. In back problems keep reminding yourself especially when walking "Straighten your back", and sleep on firm mattress face up. Then, as implied above, do not forget a risky profession like ballet dancing, a cause of crippling foot arthritis in old dancer. If you really are good at ballet, and love it, at least retire early (Before age 25). Typewriter hand arthritis should now be obsoleted. And be a bug against falls! In all cases, keep good calcium and vitamin D intake in food.
Report of Hip Replacement  The following is a self written report of right and left hip replacement in a woman who had them done in her mid 50's to early 60's because of severe degenerative arthritis. She was about 10 years post menopausal and never took hormones or calcium & vitamin D pills. First the right hip at age 54:
I prepared for the surgery by doing physical therapy. Before the surgery, I donated two units of my own blood in case I needed it. Everything went well during and after the surgery. I spent about 2 weeks at the Rehabilitation Facility, and did a lot of physical therapy there and after, as an outpatient. I had one setback when I took a bad fall on ice about 8 months after the surgery, and even the Surgeon was surprised that no damage was done to the replacement. Right after the fall I was in much pain and the whole area was black and blue for a while. I did continue with physical therapy, and I do aqua-aerobics to this day. After the wound was healed (about 3 months), I was able to go aqua-therapy in a warm pool. It has been over 12 years, and I have no pain or problem with the hip. I was in a lot of pain before the surgery. Now I have no limitations, except that it is easier to get up from the bath tub or floor by turning around and getting on my knees first.
   Eight years later, she had the left hip joint replaced as follows: I had my left hip replacement, but I did not prepare with PT beforehand. Although everything is fine now, this surgery had some complications, as my femur was cracked during the surgery, requiring two cerclage wires. This time rehab was difficult, because I wasn't supposed to put all of my weight on the hip and had to favor the right hip, which had been replaced in 2002. During PT, I noticed it was hard to breathe, and it was discovered that I also had a collapsed lung, which got better right away too. This time, I was in the hospital for almost a month. Both hips are doing great now. I have absolutely no pain and can do anything.
Comment on the Hip Replacements: The reason for the early age degenerative hip arthritis in this case is self reported as follows: "I had fallen hard on my right hip about a year or two before the surgery (and other times) and didn't take care of it. The doctors think that made it turn into arthritis. The left hip was a different pain. It started hurting years later, and would make a cracking sound whenever I stood up." (Ed: She took Calcium carbonate 500 mg and vitamin D 10 microG twice a day for years before needing the surgery. So try very hard not to fall and try to avoid especially the hard surfaces where you may fall, ie, prefer Japanese tatami floor to hard floor)
Immune System Arthritis  - Rheumatoid
Rheumatoid Arthritis I have no experience with. It starts at younger age than osteoarthritis; it is more in men. First attack goes weeks and it alarms especially when Doctor says  “Rheumatoid arthritis.” Complaint is ache in hand but it can hit any joint. In finger it involves the proximal joints compared to osteoarthritis, which involves the distal (closer to fingernails). As years pass, various joints are affected with deformity. Some patients have intestinal complaint and nodules of skin; all develop positive rheumatoid factor in blood test. It does not always cripple or seriously affect other organ function. In my observation the worst effect is fear.
I advise youth who gets a doctor’s diagnosis of it to ‘cool it’. When it is time for normal medical check, get tested for CBC and for the rheumatoid factor (RF). If RF is positive, consult a rheumatologist.
Crystal Deposition Arthritis – Gout ("Tsufu"  in Japan)
is attacks of big toe severe pain with exquisite tenderness to touch, with swelling and redness. Mostly in men and occurs after exposure of toe to cooling, as well as positions of feet that cause sluggish circulation (as in prolonged sitting). Coolness and sluggish circulation favor uric acid crystal in small blood vessel of affected joint. Dehydration (in high altitude flight) or excessive exercise promotes attack.
Gout is distinctive; anyone who has suffered one attack will diagnose it from first twinge.
Get blood test to determine uric acid. Ten mg% or higher requires uric acid lowering because of kidney stone risk; 8 to 9 mg%, needs attention to diet (low meat and other purine food) and possibly UA-lowering medicine like Zyloric. Most gout is metabolic inherited tendency to high UA but it can be due to cancer or chemo treatments, to weight loss or to too much food. To prevent UA stone, drink water, drink water, and more water.
Infection in Joint
In physically active young men, infection in a joint (knee or elbow most frequent) is complication of nearby skin infection, or else it is sex disease gonorrhea. Tuberculosis leads to infection in vertebral body joint which causes severe deformity. These infections drive victim to seek medical care because joint becomes fiery red, swollen, painful and tender.
Arthritis after  Infectious Disease
Virus infection or the bacteria, beta-hemolytic streptococcus, causes transient (days to week) migratory (from one small joint to other) joint pains with fleeting skin rash. The most infamous arthralgia-causing virus is rubella that typically involves wrists.
Pain of Muscle, Tendon, Bone, Cartilage, Ligament & Blood Vessel is in body of muscle (Charley horse in calf, or sore back) or part that attaches to bone or joint (tendonitis). It is often due to exertion such as too much walking (sole of foot) or from tennis or other sport game in poorly trained person, or in first-time jogger. Sometimes single sudden movement has pulled, stretched or partly torn a muscle. Best is an acetaminophen, and re---lax.
Bursitis and Bursal cysts - Bakers Cyst, Ganglion
Bursa is slippery sac between muscles around joint. Sometimes it gets irritated by constant small traumas, especially on side of upper arm just below shoulder (deltoid bursitis) or around knee (housemaid knee). Symptom is localized soreness with limitation of motion. Money is wasted on cortisone injection (Instead, rub in 0.12% betamethasone ointment after hot shower or bath daily for 1 week). Best is to stop the repetitive activity (baseball pitching, housework) that irritated the bursa, to use elastic band for joint where it is applicable (knee), and also local heat with acetaminophen for pain med.
   Baker's cyst is swelling behind knee from a blood cyst, sometimes after trauma. In worst case may benefit by drainage with needle by experienced physician. One meaning of ganglion is a cyst on back of hand, from bursa fluid and has old remedy of dropping a heavy book on it but best, needled by experienced doc and drained. Both types can be left alone forever.
Bone Pain
that you cannot explain by trauma and that lasts should have x-ray. Such pain may be early sign of bone infection or tumor.
Pain over jutting-out point of elbow due to trauma is ‘tennis elbow’ in middle-age man, not necessarily tennis player. It causes soreness and pain over lateral point of elbow and should be treated by elastic band on elbow and acetaminophen for the pain.
Thrombophlebitis - DVT - Pulmonary Embolism
In a leg calf, gives swelling of the one calf and ankle, and point soreness, made worse by standing on toes. Also, especially on standing, you will notice your calf on the affected side is fuller than usual and very hard all over. It is Deep Vein Thrombophlebitis (DVT). If you think you have it, eat an aspirin and get to a University-HMO (Health Maintenance Org, or hospital clinic) for diagnosis and anticoagulation to prevent blood clot to lung. (And see Pulmonary Embolism in Notebooks 6)
Reynaud's Syndrome and Reynaud's Disease
also known as Reynaud's Phenomenon is your fingers becoming hypersensitive to cold - always both hands (if one hand, suspect vascular block in arm) and episodic (coming & going with cold or other irritating stimulus). The fingers blanch and sometimes one finger is worse than others. It usually hits middle-aged persons and makes them anxious about having collagen diseases - lupus, dermatomyositis, scleroderma.Reynaud's Disease is a progressive small artery disease with symptoms like the syndrome but is progressive  and eventually causes coronary artery disease, strokes and severe migraine. In one case I know, it seems to have led to Parkinson's Disease. This case is c.60-y-o man who has had moderate Reynaud's for 10+ years. He recently reported very good results after switching from a beta-blocker to a calcium-channel blocker (Amlodipin 5mg/day). He is also taking an ACE-inhibitor (Lisinipril 5mg) and a 10mg statin pill.
Fibromyalgia
Entered our scene in 1990 a condition of persistent muscle-attachment pain with fatigue and insomnia. In 2000, six-million Americans were said to suffer it. Many appear to develop it after traumatic event: childbirth, accident, surgery, or serious illness. Diagnostic criteria are that when doctor presses one at a time on 18 designated points where muscle, tendon and ligament attach to bone, a fibromyalgia patient feels pain at 11 points or more. Fibromyalgia is controversial but in my experience, real. I got it in the neck and it gives tender scalp headaches. But do not make a big deal of it. Acetaminophen or aspirin works OK, and relaxation periods help.
Whiplash Injury Magic Cure!
Riding in car and it being struck from behind, accelerates the upper body forward, and if the head has no back support it will be jerked backward. This sudden strain causes neck pain. Before lawsuit & workman’s compensation, the whiplash cleared up with no treatment. Today, with large cash award publicized, it lasts for as long as it takes to collect. Then it disappears, usually right after a sufferer’s hand touches money. A wonder cure!
Lumbo-sacral (Lumbago) and Sacroiliac L-S Pain Disc Syndrome
In L-S, often an apparent inciting event (accident, fall, blow to back, unusual lifting and carrying, bending over) occurs and first attack is severe. Thereafter attack recurs, lasts weeks to month, often starts at worst and improves. Chronic trauma and poor postures worsen it. The attacks can recur for life. Here is my many years personal and professional experience: Pain during attack varies and one person during one attack may have more than one type pain. Worst is pain that shoots like lightning from right or left (pain mostly one sided) lumbosacral area down leg and totally causes the victim to be afraid to move. Worst pains start the attack and it improves within 24 hours. At first the patient crawls on hands and knees. By 2nd or 3rd day she is starting to walk. Strong pain medication is needed at first but by 2nd or 3rd day 500 mg acetaminophen (aka Tylenol extra-strength) and local warmth give enough relief to make life tolerable. For the rest of the attack, the pain is dull and localized. When femoral nerve root is affected, pain radiates from backbone area to hip and front of thigh on same side; when sciatic (sciatica), it goes down back of buttock and rear leg to back of heel. Sometimes an attack consists only of low back pain. Whatever type pain, certain movements worsen it. Most typical is pain on standing up after sitting on plushy cushioned sofa. Moderate walking is good and seems to end pain faster. Local heat from shower or bath helps especially for sleep at night. Firm backing of bed mattress, chair and corset is best, and back should always be supported, as in high back chair. Key is patience and understanding. Eventually as in my case the pain may become a soreness localized around waist and in front of both hip bones, worst on starting movement and thence improving but quite limiting. Aspirin 325 mg or acetaminophen 500 mg once a day has made my old age low-back-pain life barely livable. By this time MRI of lumbosacral area may show lumbo-sacral vertebrae collapse and compression fractions. Undoubtedly tension or pressure on the nerve roots are the essential cause and finally a patient may become completely invalided. Best of all is prevention while young by good posture and avoidance of falls.
 Preventive. Lie on firm mattress flat on back. Do no heavy lifting; lift by placing most tension on knees. (While lifting, keep back straight and lift with knee bend and extension) Be careful bending your back – avoid it as much as possible and do it slow and careful. On long jet flight do not stay in seat for hours. Get up and stroll.
Inter-vertebral disc hernia: Age is important here and it is not what most persons think. Serious herniated discs are most frequent in the age 20's, 30's and 40's when the disc is still gelatinous because at older ages it hardens and may crack but no hernia. The disc involved is mostly between 5th lumbar and 1st sacral (L5-S1), which is low back just above top of buttock cleft. Symptoms typically start after a flexion (bending) or a sneeze, a lurch or other sudden movement though sometime it can’t be recalled. The fully developed herniated or ruptured disc syndrome is pain in sacroiliac region radiating down one side into buttock, thigh and calf; a stiffly bent or unnatural spinal posture; and, in worst cases, pins and needles feeling in bottom of foot to toes with muscular weakness in the foot. Initially shooting pains down back of foot are frequent. MRI is the best test because noninvasive and accurate but even when it shows “bulging disc” or “herniated disc”, there is no reason to rush into surgery. Before decision for surgery, get it confirmed in second opinion by independent expert who should be a neurologist; do not depend only on orthopedic surgeon programmed in favor of disc surgery, his bread and butter operation.
Corticosteroid injections into painful joints or back should be avoided. At best they afford sometime temporary relief (More often than not they do not work) and at worst they make complications (Worst case, the recent epidemic of fungal meningitis from corticosteroid injections in back for lumbosacral or disc pains)
Malingerer and Neurotic
Since pain cannot be detected by anyone other than the sufferer, it is not surprising that a person may try to seek gain by faking it. Such case is not difficult for an alerted mind to spot. Always the pain starts suddenly in front of others, appears massive and totally disabling, with moan and groan. Bizarre contortion and posturing may be noted. Almost always the gain from the pain is avoidance of unpleasant or unwanted activity or desire not to pay a bill or the idea to initiate lawsuit.
(For friend or tour guide) Malingerer should not be confronted. Best is to try to satisfy the need, if not unreasonable. More frequent than malingering is backache complicated by neurosis. Sufferer may not be consciously aware of underlying motivation. Usually it is need for sympathy, companionship or love from previously uncaring family member, work superior, or friend. Often it is wish to get out of unhappy responsibility such as being caretaker for elderly mother or father or mothering unruly child. Neurotic backache usually has physical basis, eg, minor accident, but symptom is exaggerated and recovery delayed.
Neurotic backache should not be treated by psychoanalytic interpretation. Rather try sympathy and patience but also to protect her or him from surgery or expensive testing. It is not always possible and such patient remains at high risk for unhelpful, often harmful operation for “disc problem”. 
14. Personal Experiences with Some Joints 
 Headings in order of appearance in the text.
My Cracked Knee
Advice on Knee
Knee Replacement – Personal Vignette
Achilles Heel tendon trauma complicated by shoe
My Cracked Knee: When it comes to knee, I feel what I write. At age 15, I played the football End position. In America, football teams consist of a line with an End lineman on left and right. The End is suited for a slim, speedy lad who races off to a side to catch a football pass thrown by a line backer, and saves the game for his team by fleet-footed, broken-field runs for touchdowns. But my End ended when I leaped up to catch a football and came down hard on right knee. Within minute it was swollen and painful. X-ray showed cracked kneecap. 
  Six months and 2 ankle-to-thigh plaster casts later I finally walked without pain. My knee knitted but it became a magnet for trouble. Unpredictably I have had knee pain and swelling from minor stress from banging or from bad positioning.
Advice on Knee: In absence of accident or sports trauma, a non-discolored, mildly painful or sore knee does not need a physician. But a knee that has snapped, crackled or popped, as well as ripped; that is discolored or badly swollen; or that you are unwilling to bear weight on needs an orthopedist.
Follow up on Me: Now at age nearly 85 my knee has not bothered me for 10 years. Time and age have truly healed what had seemed a major orthopedic problem.
Knee Replacement – Personal Vignette from my late Cousin Lila in her words:
When I was 55 I was told that I needed total knee replacement. I have arthritis, & my knee was swollen, very painful. X-ray showed I had no cartilage, just bone on bone. At that time I did not want the surgery. Every now and then I would get a cortisone shot. I couldn't take anti-inflammatory med. (It upset my stomach too much, I can't take anything that contains aspirin, it makes me throw up)
Finally, after over 15 yrs (I tried every injection series that came out) I decided to have the surgery. It's my right knee, and I couldn't go from the gas pedal to the brake (in my car). I had a hard time going up and down stairs. I had a wonderful surgeon. I had all the workup before surgery, and he had me give 1 pint of my own blood (which I needed during the surgery) I had this done June 19th 2002. I was in the hospital for 5 days then went to rehab for 1 week (where I had 3 times a day for 1 hour therapy). When I went home, a therapist came to the house 5 times a week for 3 weeks. All this time (since surgery) I had a machine that bent my knee. (I had 30 staples, which they took out when I left rehab) Then I went as outpatient, 3 times a week for therapy. They had a treadmill, under water, which made it much easier to walk. For about 2-3 months, it felt as though I had a tight belt just under the knee. I used a walker for 4 weeks or so, & a cane for 1 week. It was a long haul, and at first I didn't think it was worth it, but now I do. I can stand up straight. I can walk. My knee is still a little stiff (It's now 9 1/2 months) and I have to go back the middle of June for my year checkup. It was a very long haul, but I have a better quality of life.”
 Postscript: 2 years later Lila was complaining bitterly about recurrence of her knee pain. The lesson here is that initial satisfying result may deteriorate into failure. Post-postscript: 3 years later, Lila died from cancer. She might well have waited out the desire for surgery. Note that this was knee replacement; my contacts reveal that hip replacement is better than knee for permanent pain relief and resuming natural gait.
Achilles Heel tendon trauma complicated by shoe
Several years ago someone bought me a new pair of shoes. They were a hard leather-like shoe. One day, I had to attend a funeral and having no formal shoes decided to wear the gift pair just the few hours. A day or so later I began to notice soreness and swelling over and around my right heel tendon and it worsened over next days so much I almost could not walk. I had the foot x-ray'd. It showed a 1 cm diameter calcification at lowest part of the muscle that forms the right Achilles tendon. My joint doctor explained it was old trauma calcification and, because of the hard back-edge irritation due to the gift shoe, it had swollen and become tender. He advised no treatment except avoiding trauma. I used acetaminophen. It cleared up.  Several years later I got a recurrence due to stretching my leg out from a chair. The pain subsided over a week, helped by acetaminophen, I stopped putting my feet up in that away from that moment on and since then have been fine.
There is a lesson here beyond avoiding trauma and beside being careful to wear comfortably fitted shoe. Avoid strong treatment (like arthroscopy or other surgery to remove an irritating calcification) and give magnificent neglect a good college try helped by acetaminophen.
Neck: Everyone is going to have a problem with neck sprain some time during life.  either from motor vehicle accident or poor posture. A Cervical collar for a week or two should solve the problem. Except for severe trauma the neck bones should not be a serious source of worry. In general MRI and CT of chronic neck discomfort tend to be over interpreted and unless definite fracture or dislocation, abnormal findings should be sat on and treated with the famous remedy: tincture of time or also called Do nothing until it gets better. Advice on posture and position is: while walking look up and straight ahead mostly and only occasionally glance at ground for obstacles. Watching TV or computer screen take breaks where you gaze into distance. or just lie down on back with head extended.

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